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Acute Articular Rheumatism.

Synonyms.—Inflammatory Rheumatism; Rheumatic Fever; Acute Rheumatism.

Symptoms.—Incubation.—The period of incubation is short and not characteristic. There may be prodromal symptoms, consisting of malaise, stiffness, painful condition of the joints, and sore throat, especially tonsillitis. Usually, however, the disease is ushered in with chilly sensations, or even a rigor. The fever rapidly rises to 103° or 104°; there is not only pain in the head and back, but soreness of the whole body; the skin is hot, though often moist; the tongue is white and furred, the bowels constipated, and the secretion from the kidneys scanty, high-colored, and excessively acid; the pulse is full and frequent, ranging" from 100 to 140 beats per minute.

With the advent of the fever, a joint, usually the knee, ankle, elbow, or wrist, begins to swell and becomes red, hot, and exquisitely painful. If the joint is moved, the patient cries out with pain, and even the presence of the bedclothes may cause suffering. The fever may run quite high for several days, and then gradually decline. The mind remains clear save when the temperature is excessively high.

Some time during the twenty-four hours, usually at night, the patient breaks out in a profuse perspiration, which is of a sour odor, and is often attended by sudamina and miliary vesicles. These daily or nightly sweats leave the patient quite prostrated for a time; after twenty-four or forty-eight hours of heat and pain in a joint, the swelling begins to subside, the color and pain disappear, and the part, though tender, takes on a normal appearance; but, to the disgust of patient and physician, the swelling, heat, pain, and redness occupy the attention of its opposite fellow, or perhaps another member on the same side. Thus it may go from joint to joint, or alternate with the part first affected. The swelling varies, usually confined to the joint, though often involving the s-heaths and tendons.

The blood-changes are very marked, few diseases showing the marked anemia of rheumatism. The duration of the disease is variable, and no one can tell at the beginning of an attack whether it will terminate in six days or six weeks. It is one of the most painful and distressing of all diseases. Day after day the patient may lie with a red, puffy, and tender joint, unable to move it without the greatest pain, and, to add to his discomfort, a profuse, sour sweat occurs, the odor of which adds to his misery. As the days pass, the sweat loses its acidity, and may even become alkaline.

The heart may early feel the force of the infection, and the murmur in the apex region is the note of warning. This organ should be examined daily that we may be prepared with treatment to modify the force of the disease.

"In subacute rheumatism there is usually but little fever; the pulse may be increased five or ten beats per minute, and be more full and bounding or hard, the skin harsh and dry, the tongue coated, the appetite somewhat impaired, bowels constipated, and the urine scanty and deeper colored. These symptoms follow instead of preceding the local affection.

"One or more parts may be affected, the larger joints suffering most frequently, the smaller ones next, and the aponeurotic expansions and muscles least. When a part is attacked, it commences to swell, and becomes hot and painful, though in many cases it is not reddened. The pain, as in the preceding cases, is gnawing, tearing, tensive, and contusive, or lancinating, though usually not so severe as in the acute form. It does not change its position so frequently, but still a metastasis is not uncommon. It is full as stubborn as the more acute malady."

Complications.—The most serious and really the only complications that need be considered are those affecting the heart, occurring most frequently in the acute form, though found both in the subacute and the chronic. It occurs far more frequently in the young than in those past middle life. Dr. Peacock found that thirty-three and a third per cent occurred under twenty-one years of age, and only sixteen and six-tenths per cent after forty years of age.

The left heart is nearly always the seat of the lesion, for the same reason that the larger joints are almost invariably the seat of the local trouble; viz., greater functional activity.

Formerly it was supposed that the cardiac lesion was the result of a metastasis from some other part, but this idea has given way to the more rational one of similarity of structure to that of the joints; viz., fibrous and serous, and though the structure of. the right heart is the same as that of the left, there is much less functional activity of the right. Its walls are thinner, and there is less tendinous material in its valves. The work is not so severe and the strain not so great. It has been determined that the left heart bears three times the strain of the right; hence the greater functional activity and greater susceptibility to inflammation.

Endocarditis.—This is the most frequent as well as the most serious complication, for it involves the mitral segments, and, though rarely dangerous, it is apt to set in motion changes which result in chronic valvular troubles, that influence the heart's action throughout life. With each attack of rheumatism, the liability to this complication increases.

The symptoms are rather vague, and many times are overlooked. An increased frequency of pulse, and an increased temperature without an increase of the local joint affection, should arouse suspicion and turn our attention to the heart.

Pericarditis.—This is rarely found as a primary disease, but follows various infectious lesions, and, in from sixty to eighty per cent, can be traced to rheumatism, and though one of the most common of complications, like endocarditis, is often overlooked during life, and only revealed post-mortem while searching for other lesions. It may occur with endocarditis or independently of that affection.

Myocarditis.—This is not so common a lesion, and when it does occur, is preceded by the above-mentioned complications.

Diagnosis.—"We have but little trouble in making the diagnosis of rheumatism, the swelling, heat, and peculiar character of the pain being generally sufficient. It is true that, in cases of disease of the bones or of the cartilages or synovial membrane of a joint, it is sometimes almost impossible; yet the character of the pain, the general condition of the system, and the fact that rheumatism is rarely confined to one point, will frequently enable us to decide.

"Rheumatism of the back, or lumbago, is sometimes mistaken for disease of the kidney or spinal cord; but if we recollect that, in disease of the kidney, we will usually have retraction and pain in the testicle, change in the character of the urine secreted, and more or less constitutional disturbance peculiar to suppression of the urine, and that in disease of the spinal cord to this extent, we would have disturbance of all the nerves given off below, we will not readily make the mistake.

"Neuralgia is very frequently confounded with rheumatism, and it is sometimes almost impossible to distinguish them; but in a majority of cases, the pain, being exquisitely sharp, tearing or lancinating, and in the course of a nerve, will enable us to see that it is neuralgia."

Gout usually occurs in the smaller joints, preferably the great toe; then the age, habits, and history of onset will help us in recognizing the one from the other. We can distinguish rheumatism from arthritis, by the history of pyemia, and the inflammation terminating in suppuration, and the more or less destruction of the joint.

Prognosis.—This is nearly always favorable, for though the heart complications are frequent, they rarely cause death. Our prognosis, therefore, is favorable as to life, but uncertain as to length of time the disease will run; for of all diseases that affect the human race, rheumatism is the most uncertain. Some very severe forms will yield in eight or ten days, while others seemingly not so severe will run eight or ten weeks.

Treatment.—Specific medicines yield better results than the so-called rheumatic combinations, and if a careful selection is made according to specific conditions, the majority of cases will yield more speedily than under the old regime.

The patient should be placed between blankets, and wear a flannel night-dress, with the sleeves open from shoulder to wrist, that we may readily get at elbow and wrist. The patient is less apt to take cold after profuse sweating if protected by flannel.

Locally, the part should be wrapt in cotton, or what is better, raw wool. Where the pain is great, chloroform liniment is often of much benefit. A favorite local remedy is camphor and turpentine, of each one ounce, and alcohol two ounces.

If seen early, the old alcohol sweat is of great benefit. Have the patient disrobed and placed on a wooden bottom chair, with a blanket covering him from the neck to the floor. Place four ounces of alcohol in a cup, which should be set in a pan of water, and this placed under the chair; have the patient's feet in a deep bucket of hot water; light the alcohol, and the patient will soon reach the sweating stage. Allow the patient to drink freely of cold water; the perspiration will soon start from every pore, and after ten or twenty minutes of this treatment, place the patient in bed with hot-water bottles to feet, and in a few minutes the patient falls into a quiet sleep. Where this is carefully followed, I know of no treatment which' will so successfully cut short the disease.

Internally, for the full, strong pulse, I use veratrum in full doses, say thirty or forty drops to half a glass of water, to which I add sulphate of morphia, a half grain. This overcomes the nausea occasioned by the veratrum, and also assists in relieving pain. To the sedative may be added bryonia, five to ten drops, especially where the pain is lancinating in character.

Where there is great muscular soreness, use macrotys, and give in rather large doses, say one or two drams to half a glass of water. Dr. Webster speaks very highly of Rhamnus californica in stubborn cases, and from what I have seen of its effects, I like its action very much.,

Where the parts are swollen and there is edema, apocynum is the remedy, and if there arise heart complications, it is the remedy par excellence. I know of no other remedy which can equal it under these conditions; the decoction gives the best results.

Where the tongue is broad and full, and there is puffiness under the eyes, potassium acetate will give good results. A good combination is salicylic acid one dram, potassium acetate four drams, water four ounces; a teaspoonful every four hours, the patient drinking freely of water after each dose.

Where the tongue has a pasty, dirty fur upon it, a saturated solution of sodium sulphite gives good results; but if the tongue be white, but clean, sodium salicylate in five-grain doses every three hours will replace the sulphite.

Often we have the red tongue and mucous membrane; here muriatic acid takes the place of the alkali; lemon-juice is also grateful and beneficial.

Where the pain is unbearable, a hypodermic of morphia may be necessary to give relief, but this should be avoided, except in extreme cases. Blisters should be discarded, for while they may give temporary relief, the after effects are so painful that the good is counterbalanced by the suffering.

The diet should be light, milk in some form being the best, cow's milk, malted milk, broth, whey, or koumiss. Where the patient can not take milk, broths may be substituted. Avoid meats and starchy and sweet foods till all fever disappears and secretions are fully established.

The treatment for the subacute form will be very much the same, minus the sedatives, and even here there may be indications for the small dose. Gentle massage will often afford much relief.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.

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